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Methodological Validation and Clinical Usefulness of Carbon-14-Urea Breath Test for Documentation of Presence and Eradication of Helicobacter Pylori Infection

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Methodological Validation and Clinical Usefulness of Carbon-14-Urea Breath Test for Documentation of Presence and Eradication of Helicobacter Pylori Infection Methodological Validation and Clinical Usefulness of Carbon-14-Urea Breath Test for Documentation of Presence and Eradication of Helicobacter pylori Infection JoëlJ. Desroches, Raymond G. Lahaie, Michel Picard, Jacques Moráis,AndréDumont, Christiane Gaudreau, Daniel Picard and Raymonde Chartrand Departments of Nuclear Medicine, Gastroenterology, Pathology and Microbiology, Hôpital Saint-Luc, University of Montreal, Montreal, Canada whereas the recurrence rate is only 10%-15% when a triple A simple [14C]urea breath test (C-14-UBT) was validated with aims antibiotic regimen against H. pylori is added (3,6). The Con of determining accuracy in documenting both the presence and sensus Development Conference of the National Institutes of proof of eradication of Helicobacter pylori infection. Methods: Fifty-six dyspeptic patients had endoscopy with biopsies and C-14- Health (9) recommended that all patients with peptic ulcers who UBT. Eleven biopsy-proven H. py/or/-negative patients allowed are infected with H. pylori receive antimicrobial therapy. H. C-14-UBT normal value determination. Forty-three patients with pylori status determination has hence become a necessary tool recurrent peptic ulcer disease and biopsy-proven H. pylori infection to guide the therapy of peptic ulcer disease. were included in an antimicrobial eradication protocol. Endoscopy Diagnosis of H. pylori infection can be reliably achieved with biopsies and C-14-UBT were done again 8 wk after initiation of during endoscopy by histologie analysis or culture of biopsy treatment in 35 patients. For C-14-UBT, 185 kBq (5 ßCt)of [14C]urea specimens (10-12). The unique urease-producing capability of was swallowed. Breath samples obtained up to 20 min were counted to calculate AS20, [(% 14CO2dose excreted/mmol of C02) these bacteria has also been used to detect them through urease testing of endoscopie biopsies. However, these procedures that x kg] at 20 min. Combined histologie and microbiologie analyses of require endoscopy were invasive, and simpler means of detec antral biopsies were used as a gold standard. Results: The positivity value was set as AS20 > 0.33% (mean + 3 s.d. of AS20 in H. tion were sought. While serology (ELISA) is simple, it cannot py/or/'-negative patients). Diagnosis of H. pylori infection was correct differentiate active from remote infection, nor can it quickly with C-14-UBT in 55/56 patients (44 true-positive, 11 true-negative document H. pylori eradication after treatment (3,6,10). Urea and 1 false-negative; sensitivity = 98%; specificity = 100%). As a breath testing was suggested as a promising noninvasive alter proof of eradication, C-14-UBT correctly classified 33/35 patients (5 native for these purposes (10,13-21). If H. pylori is present in true-positive, 28 true-negative and 2 false-positive; sensitivity = the stomach, its urease will hydrolyze urea labeled with 100%; specificity = 93%). The C-14-UBT global performance carbon-13 or carbon-14 isotopes. The labeled H*CO3~ will be yielded sensitivity, specificity and accuracy of 98%, 95% and 97%, absorbed in the stomach and will diffuse in blood to be excreted respectively. A significant correlation (r = 0.84) was found between by the lungs as *CO2 that can be collected in breath samples. AS20 and the number of H. pylori colonies on culture. Conclusion: While both isotopes seem to offer similar diagnostic accuracy, This C-14-UBT is highly accurate both for diagnosis and proof of the 13C-urea breath test has the potential inconvenience of eradication of H. pylori infection and reflects the antral bacterial load. It is simple, fast and inexpensive, and it is therefore suitable for requiring more complex equipment, and it is more expensive. In clinical practice. addition, it usually requires the administration of a test meal and Key Words: Helicobacter pylori; urea breath test; carbon-urea; cold urea to the patient. This is not necessary with carbon-14, peptic ulcer disease; gastritis and the test is thus simpler, faster and more likely to achieve J NucíMed 1997; 38:1141-1145 clinical acceptance. This paper describes the use of a simple and quantitative MC-ureabreath test (C-14-UBT) in our institution. The aims of flelicobacter pylori was first identified and isolated by this study were: (a) to present a methodological validation of Marshall in 1983 (/). It is a gram-negative, urease-producing the test and determine normal values; (b) to determine its spiraled rod that has since been proven to be responsible for accuracy for detection of//, pylori infection; (c) to determine its type B chronic antral gastritis (2-8). H. pylori infection is now accuracy as a proof of//. pylori eradication after therapy; (d) to known to be the main cause of peptic ulcer disease and has been determine global performance of the test and (e) to show the associated with atrophie gastritis, gastric carcinoma and nonul- ability of the test to provide a semiquantitative evaluation of the cer dyspepsia (2-7). Recent studies have showed presence of//. antral bacterial load. pylori in more than 95% of duodenal ulcers and in 80%-95% of gastric ulcers not associated with nonsteroidal anti-inflamma MATERIALS AND METHODS tory drugs (2-4,6). The importance of//, pylori in the clinical Patients setting is related to ulcer recurrence. After I yr, between 55% For the methodological validation part of the study, 56 referred and 90% of ulcers recur when treated with anti-H2 therapy only, patients with persistent dyspepsia were recruited. After informed consent was obtained, all underwent upper gastrointestinal endos copy with antral biopsies as well as a '4C-urea breath test within 1 Received Apr. 12, 1996; revision accepted Sep. 19, 1996. For correspondence contact: JoëlJ. Desroches, MD, 950 Boulevard Mauricien, wk. H. pylori status was determined as described in the following Trois-Rivières-Ouest, Quebec, Canada, G9B 1V7. section, and the results of '4C-urea breath tests were then analyzed For reprints contact: Jacques Moráis,MD. Department of Nuclear Medicine, Hôpital Saint-Luc, 1058 Saint-Denis, Montreal, Quebec, Canada, H2X 3J4. against this gold standard in order to determine a cutoff value of UREABREATHTESTINH. pylori INFECTION•Desroches et al. 1141 MOUTH PIECE UNIDIRECTIONAL VALVE CONNECTING TUBE AIR OUTFLOW AIR INFLOW FIGURE 1. Apparatus for the 14C-urea CAP breath test. A disposable mouthpiece and unidirectional valve are linked to a connecting tube to a hole in the cap of a scintillation vial into which another hole is VIAL WITH pierced to allow air to be expelled. Vials TRAPPING SOLUTION with C0? trapping solution are succes sively attached to this cap. positivity. Evaluation of the accuracy of the l4C-urea breath test for Readings were done at 3 and 7 days. The bacterial load was detection of H. pylori infection was then performed. assessed semiquantitatively as 0 (no growth), 1+, 2+ or 3+ , Of the 56 patients, all those shown to be H. pv/or/'-positive by according to an estimate of the number of colonies on culture plate. analysis of antral biopsies performed during the upper gastrointes Our criteria for H. pylori positivity required the presence of at tinal endoscopy and known to have had at least one episode of least one of the following: (a) histologie identification of H. pvlori ulcers in the past were recruited for a H. pylori eradication or (b) microbiologie evidence of//, pylori on culture. A patient was protocol. Forty-three patients were thus randomized to one of three considered //. pv/or;'-negative when both criteria were absent. therapeutic regimens against H. pylori (22). Thirty-five patients These criteria we used are recognized in the literature as the gold had both an upper gastrointestinal endoscopy and a l4C-urea breath standard for H. pylori status determination. test done 8 wk after initiation of the 2-wk therapy against H. pylori. Carbon-14-Urea Breath Test Using the same cutoff value of positivity as above, these patients allowed evaluation of the performance of the '4C-urea breath test Materials. The apparatus is described in Figure I and consists of a 30-cm flexible plastic tube with, at one end, a mouthpiece as a proof of eradication of H. pylori infection. The global performance of our l4C-urea breath test (i.e., for connected to a unidirectional valve preventing any accidental aspiration of the trapping solution. The other end has an adapter diagnosis and eradication) was also assessed by analyzing the 91 linking the tube to a hole in the cap of a scintillation vial into which breath tests performed on the 56 patients. Finally, 48 of these another hole is pierced to allow air to be expelled when patients patients who had antral biopsies and cultures for H. pvlori were used to show the ability of our l4C-urea breath test to provide a breathe. The cap end allows vials to be attached for CO2 trapping. Each 25-ml vial contains 4 ml of benzethonium hydroxide (0.5 semiquantitative evaluation of the antral bacterial load. This was achieved by comparing the breath I4CO2 specific activity with a mmol/ml) in pure ethanol with lOOju.lof thymolphthalein (0.05%). semiquantitative evaluation (0-3 + ) of the number of H. pylori This bluish solution turns colorless when 2 mmol of CO2 are trapped in it. Four vials labeled TO, T5, TÕOand T20 were initially colonies on a culture plate. used for patients in our protocol (0-, 5-, 10- and 20-min breath Helicobacter pylori Status Determination samples). Carbon-14-urea is supplied as a freeze-dried solid, sealed Upper Gastrointestinal Endoscopy. During the standard upper under nitrogen in a borosilicate vial containing 9.25 MBq (250 gastrointestinal endoscopy, three or four antral biopsies were /iCi). This is dissolved in 50 ml of ethanol and stored in a obtained within 5 cm of the pylorus.
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